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Prognosis of Anterior Septal Hypokinesia?
General: 64 year old male, cardio exercise 30 min 4-5 times per week. Recent stress echo Bruce protocol 13 minutes, 13.34 mets, VO2max 46.288, score 98. Max Heart Rate (182), not recommended to exceed MHR, but felt good and tech allowed. Last stress test, non echo, 1 year ago, 13.45 minutes. three years ago 15 minutes.
Echo stress report: Suggested by Cardiologist to establish base line.
Base Line images revealed normal LV size and systolic function with no segmental wall motion abnormalities identified. Repeat images a peak stress demonstrated mild anteroseptal hypokinesis. There were no exercise induced arrhythmias however, EKG at peak stress was difficult to interpret.
2 Dimensional Doppler Echo numbers
Aortic Root 3.4, Left Atrium 3.6, LVEDD 5.1, LVESD 3.3, IVS 1.3, LVPW 1.3, E.F. approx. 60%
Interpretion; 1. Technically difficult study, 2. Normal LV size and function, 3. Mild LVH, 4. Mild AV sclerosis with normal leaflet motion. MV, TV appear normal. There is trace MR and mild TR with RVSP=30-35mmHg, 5. RA/RV appear normal in size and function, 6. No significant pericardial effusion or intracavitary echo densities seen. Conclusions
1.T.D.S with adequate data quality, 2. Normal L.V. size and function with 60% EF, 3. No significant valve disease.
Cardiologist recommended a SPECT stress echo, however insurance company declined coverage even after peer to peer review.
So what does this all mean? I think is fair to assume that at my age and subject to an American diet, that there some level of stenosis in my coronary arteries. The location and level of occlusion is unknown and without further testing we can only approximate based on the previous echo numbers. That said, where do we go from here? Based on the echo numbers, what is my prognosis and is a stress profusion test, paid for out of pocket, worth the time and expense? Or, is a CTA or cath angiogram a better approach, although much more expensive.
Septal Hypokensia is a wall motion defect, although mild in my case. However is does imply some level of occlusion, and in my case possibly LAD associated, and therefor potentially dangerous to ignore. So essentially we are left to guess, without insurance support, about possible outcomes.
Can you all put the echo numbers in perspective for me and possibly provide some direction? Also, is it possible that by exceeding my MHR during the stress test that the numbers or indications may have been effected, or skewed?
Regards............JM
Echo stress report: Suggested by Cardiologist to establish base line.
Base Line images revealed normal LV size and systolic function with no segmental wall motion abnormalities identified. Repeat images a peak stress demonstrated mild anteroseptal hypokinesis. There were no exercise induced arrhythmias however, EKG at peak stress was difficult to interpret.
2 Dimensional Doppler Echo numbers
Aortic Root 3.4, Left Atrium 3.6, LVEDD 5.1, LVESD 3.3, IVS 1.3, LVPW 1.3, E.F. approx. 60%
Interpretion; 1. Technically difficult study, 2. Normal LV size and function, 3. Mild LVH, 4. Mild AV sclerosis with normal leaflet motion. MV, TV appear normal. There is trace MR and mild TR with RVSP=30-35mmHg, 5. RA/RV appear normal in size and function, 6. No significant pericardial effusion or intracavitary echo densities seen. Conclusions
1.T.D.S with adequate data quality, 2. Normal L.V. size and function with 60% EF, 3. No significant valve disease.
Cardiologist recommended a SPECT stress echo, however insurance company declined coverage even after peer to peer review.
So what does this all mean? I think is fair to assume that at my age and subject to an American diet, that there some level of stenosis in my coronary arteries. The location and level of occlusion is unknown and without further testing we can only approximate based on the previous echo numbers. That said, where do we go from here? Based on the echo numbers, what is my prognosis and is a stress profusion test, paid for out of pocket, worth the time and expense? Or, is a CTA or cath angiogram a better approach, although much more expensive.
Septal Hypokensia is a wall motion defect, although mild in my case. However is does imply some level of occlusion, and in my case possibly LAD associated, and therefor potentially dangerous to ignore. So essentially we are left to guess, without insurance support, about possible outcomes.
Can you all put the echo numbers in perspective for me and possibly provide some direction? Also, is it possible that by exceeding my MHR during the stress test that the numbers or indications may have been effected, or skewed?
Regards............JM
Thanks again Circa49 for sharing your experiences and for your reasurrances. I have taken a statin and 81mg asprin for the last 15 years and I watch my diet very carefully. And your explanation of relative MHR and the need for individual assesssment makes good sense. If the tests we undergo don't stress the heart enough to revieal existing issues, than what's the point. I will take solice from your comments and do agree that good functional capacity, 13.3 Mets, is a strong prognostic indicator for avoiding future cardiac events. Sometimes, when faced with potentially serious health issues. we have a tendency to overprocees and obsess on the negative. Thanks again for all your time and personal insight.
Best Regards...............JM
Best Regards...............JM
Just in case you didn't know it, you can join Medicare November 1st.
You join on the first day of the month in which your 65th birth day fall.
Regarding your risk over the next 11 months, I would say there is very minimal chance of anything happening. Very minimal.
But you seem to have heighted concerns.
As such, how much care have you taken to make significant changes in your diet? Is your cholesterol high or very low?
Let me give you one piece of advice regarding a Nuclear Stress Test (SPECT). I had one in 2012 at age 62. I was told nothing abnormal showed up.
However now that I know more about that test, I would try to make sure it was valid test..
Here was my problem with the "normal' testing protocol.
Unless you get their attention, they often only run you up to 85% of your calculated maximum heart rate.
The problem is that many men have much higher than average maximum heart rate.
Mine is not as high as yours,, but it is still perhaps 6 beats per minute above the projected maximum.
Anyway, they only took mine up to 142 being that at age 62, 85% only equals about 134 or 135. So my 142, in their mind was 90% of max.
However for me, it was only about 87%, barely high enough to meet the minimum standards.
Higher rates give a better more accurate picture of any ischemia, but I think they fear giving many of the sick participants a heart attack if they take them much beyond 85%.
So guys like you and me, who during our normal activities, take our heart rates much higher, may be given a test that really doesn't test high enough to produce the ischemia they are searching for.
In my mind, you should be take up to a minimum of 155 (85% of 182) and actually 90% x 182 would be better at 164 heart rate.
After all, you've got to put some stress on the heart to produce the ischemia you are searching for.
Get that all cleared up before you have any nuclear stress test done.
I got a all clear, but the bit of angina I was feeling on my bike rides only barely kicked in at 142 heart rate. I felt they should have taken me up to where I was experiencing the angina symptoms to get the ischemia that produces the angina feelings.
Study and understand this article regarding the need to get to adequate heart rates in stress tests
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996150/
"CONCLUSION: Aerobic exercise testing is an integral component in the assessment of patients with suspected myocardial ischemia. Our findings indicate that the currently used percentage of APMHR and peak RPP thresholds are ineffective in quantifying a patient's level of exertion during exercise stress testing."
Just because your original stress test was given where they took you up to adequate levels, does NOT mean the operator will take you up to a high enough level in your Nuclear profusion test.
Their instructions may well be to only take you to 85% or 90% of what a person's your age maximum heart rate is suppose to be (220 minus age)
I felt my nuclear perfusion test was somewhat wasted because I was never taken to a level where I would normally feel the angina I felt on my bike rides. The perfusion test is showing any differences in the appearance and if one is not taken to the levels where ischemia in one part of the heart would produce differences, then what is there to compare?
OK study such things before you go in for a test. Make sure your doctor passes on instructions to the testing nurse so she will allow you to go to high enough exertion levels. Don't assume anyone will tell her, not even if she is the same person who did the original stress test.
Because these tests have different aims and criteria.
Hope that saves you from getting results such as I got, where I think there is a significant possibility of it being a "false negative" reading.
On the other hand,, I still don't think you are in danger now.
If you look around and read, as I have been doing for the past 18 months, you'll see that outcomes of men with over 13 mets are just very good in extremely high percentage.
That one fact, of a 13.3 mets output, really outweighs most of the other concerns. Really, it does.
I still get my angina during my first 4 to 14 minutes of out of the saddle climbing on my bike, called "walk through angina" or so I theorize.
But given my mets output about 13.5 to 14.0+ I'm not overly concerned about having a cardiac "event" on my rides.
Anyway, interesting, as we are only about 1 month difference in age and both really fit compared to most men. Good for us!
OH yeah, about your diet. I've gone for many years, for non heart related reasons,, to a diet similar to that of Dean Ornish.
I'm not a full on vegetarian or vegan, but eat mostly in that direction with only very small portions of animal products, meat, dairy etc.
The typical American Heart Association diet hardly goes far enough to stop the progression of heart disease that most American men have.
But I only began eating that way about 8 years ago, so I had about 55 years of the more typical American diet which leads to so much heart disease.
You join on the first day of the month in which your 65th birth day fall.
Regarding your risk over the next 11 months, I would say there is very minimal chance of anything happening. Very minimal.
But you seem to have heighted concerns.
As such, how much care have you taken to make significant changes in your diet? Is your cholesterol high or very low?
Let me give you one piece of advice regarding a Nuclear Stress Test (SPECT). I had one in 2012 at age 62. I was told nothing abnormal showed up.
However now that I know more about that test, I would try to make sure it was valid test..
Here was my problem with the "normal' testing protocol.
Unless you get their attention, they often only run you up to 85% of your calculated maximum heart rate.
The problem is that many men have much higher than average maximum heart rate.
Mine is not as high as yours,, but it is still perhaps 6 beats per minute above the projected maximum.
Anyway, they only took mine up to 142 being that at age 62, 85% only equals about 134 or 135. So my 142, in their mind was 90% of max.
However for me, it was only about 87%, barely high enough to meet the minimum standards.
Higher rates give a better more accurate picture of any ischemia, but I think they fear giving many of the sick participants a heart attack if they take them much beyond 85%.
So guys like you and me, who during our normal activities, take our heart rates much higher, may be given a test that really doesn't test high enough to produce the ischemia they are searching for.
In my mind, you should be take up to a minimum of 155 (85% of 182) and actually 90% x 182 would be better at 164 heart rate.
After all, you've got to put some stress on the heart to produce the ischemia you are searching for.
Get that all cleared up before you have any nuclear stress test done.
I got a all clear, but the bit of angina I was feeling on my bike rides only barely kicked in at 142 heart rate. I felt they should have taken me up to where I was experiencing the angina symptoms to get the ischemia that produces the angina feelings.
Study and understand this article regarding the need to get to adequate heart rates in stress tests
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996150/
"CONCLUSION: Aerobic exercise testing is an integral component in the assessment of patients with suspected myocardial ischemia. Our findings indicate that the currently used percentage of APMHR and peak RPP thresholds are ineffective in quantifying a patient's level of exertion during exercise stress testing."
Just because your original stress test was given where they took you up to adequate levels, does NOT mean the operator will take you up to a high enough level in your Nuclear profusion test.
Their instructions may well be to only take you to 85% or 90% of what a person's your age maximum heart rate is suppose to be (220 minus age)
I felt my nuclear perfusion test was somewhat wasted because I was never taken to a level where I would normally feel the angina I felt on my bike rides. The perfusion test is showing any differences in the appearance and if one is not taken to the levels where ischemia in one part of the heart would produce differences, then what is there to compare?
OK study such things before you go in for a test. Make sure your doctor passes on instructions to the testing nurse so she will allow you to go to high enough exertion levels. Don't assume anyone will tell her, not even if she is the same person who did the original stress test.
Because these tests have different aims and criteria.
Hope that saves you from getting results such as I got, where I think there is a significant possibility of it being a "false negative" reading.
On the other hand,, I still don't think you are in danger now.
If you look around and read, as I have been doing for the past 18 months, you'll see that outcomes of men with over 13 mets are just very good in extremely high percentage.
That one fact, of a 13.3 mets output, really outweighs most of the other concerns. Really, it does.
I still get my angina during my first 4 to 14 minutes of out of the saddle climbing on my bike, called "walk through angina" or so I theorize.
But given my mets output about 13.5 to 14.0+ I'm not overly concerned about having a cardiac "event" on my rides.
Anyway, interesting, as we are only about 1 month difference in age and both really fit compared to most men. Good for us!
OH yeah, about your diet. I've gone for many years, for non heart related reasons,, to a diet similar to that of Dean Ornish.
I'm not a full on vegetarian or vegan, but eat mostly in that direction with only very small portions of animal products, meat, dairy etc.
The typical American Heart Association diet hardly goes far enough to stop the progression of heart disease that most American men have.
But I only began eating that way about 8 years ago, so I had about 55 years of the more typical American diet which leads to so much heart disease.
Thank you Circa49, your frank and insightful assessment is appreciated.
Just turned 64 Nov 25 2013, so about a year I guess for Medicare, if it's still around when I get there?
More importantly, I had experienced some mild dyspnea (shortness of breath) while jogging, but towards the end of my run. No chest pain, but enough to catch my attention and that of my cardiologist, ergo the Echocardiam.
With a diagnosis of "Mild Anterior Septal Hypokensia" one has to look for the underlying reasons for such a condition and it's etiology. The septal wall between left and right ventricals is not functioning quite as well as it should, so you have to ask the question why and what are the implications. What feeds this wall and the myocardial tissue of the left ventrical is the LAD (Left Decending Coronary Artery) colloquially known as the "Widow Maker". The implication here is that there is some level of occulsion (blockage) within the LAD, reducing the amount of oxygen to this area of heart muscle (Ischemia). The potential for a cardiac event, even with great functional capaicty (13.3 Mets), "is" a real concern anytime the LAD comes into question, thus the apparent reason for ordering the Nuclear Stress Test (SPECT).
In my opinion, dismissing such a diagnosis, even in light of other positive indications, would not be prudent. Waiting a year for Medicare might assuage some of the financial concerns, but it does little to address the underlying possiblility that something insidious may be occurring.
My reason for reaching out to the Medhelp community was to get additional information from other folks who may have had a similar diagnosis.
As a practicle matter, my very high deductable has been met and may max out of pocket is within reach, so if any other diagnostic tests or interventions were justified, and approved by the insurance co., now is the time to proceed.
Your perspective is appreciated. Thanks
Just turned 64 Nov 25 2013, so about a year I guess for Medicare, if it's still around when I get there?
More importantly, I had experienced some mild dyspnea (shortness of breath) while jogging, but towards the end of my run. No chest pain, but enough to catch my attention and that of my cardiologist, ergo the Echocardiam.
With a diagnosis of "Mild Anterior Septal Hypokensia" one has to look for the underlying reasons for such a condition and it's etiology. The septal wall between left and right ventricals is not functioning quite as well as it should, so you have to ask the question why and what are the implications. What feeds this wall and the myocardial tissue of the left ventrical is the LAD (Left Decending Coronary Artery) colloquially known as the "Widow Maker". The implication here is that there is some level of occulsion (blockage) within the LAD, reducing the amount of oxygen to this area of heart muscle (Ischemia). The potential for a cardiac event, even with great functional capaicty (13.3 Mets), "is" a real concern anytime the LAD comes into question, thus the apparent reason for ordering the Nuclear Stress Test (SPECT).
In my opinion, dismissing such a diagnosis, even in light of other positive indications, would not be prudent. Waiting a year for Medicare might assuage some of the financial concerns, but it does little to address the underlying possiblility that something insidious may be occurring.
My reason for reaching out to the Medhelp community was to get additional information from other folks who may have had a similar diagnosis.
As a practicle matter, my very high deductable has been met and may max out of pocket is within reach, so if any other diagnostic tests or interventions were justified, and approved by the insurance co., now is the time to proceed.
Your perspective is appreciated. Thanks
COMMUNITY LEADER
I think overall your echo is fine but I'm not a doctor. One thing that stands out is that the report states it was a technically difficult study which may mean the images were not clear so the mild Hypokensia may be a false positive. I'm sure your doctor is being cautious but your insurance company feels your echo results are good, which they are. 13 plus mins with an mets achieved over 13 along with a heart rate over max would indicate good overall health of your cardio vascular system. You heart has no structural anomalies other than mild LVH at 1.3 which should be under 1.2, but that's common as we age and no where near the level of concern.
So of it were me I would discuss this result with my doctor and understand why he wants more testing. You have the option of going forward but you would have to do it out of pocket, it really depends on what your doctor says and your level of assurance.
So of it were me I would discuss this result with my doctor and understand why he wants more testing. You have the option of going forward but you would have to do it out of pocket, it really depends on what your doctor says and your level of assurance.
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You are 64. In less than 12 months, perhaps only 3 months, you will turn 65 and be on Medicare. At that point you won't have to worry about coming up with much money depending on your particular Medicare provider.
So, are you actually concerned about waiting a few months?
Are you experiencing some problems, or angina when you exercise?
Otherwise your numbers indicate you are very unlikely to have a serious heart problem in the next few months (probably not even in the next few years)
Even men able to put out 10 mets are considered a safe bet over the next year or so.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2826719/
You are way beyond 10 mets. There are sedentary men and their are active men. If you look at charts, your mets output is 150% of the output of 'active' 64 year old men.
As your report indicated you are at the 98th percentile.
Meaning only 2 men in 100 are doing better on the treadmill.
I turn 64 in December and I do about what you do on the treadmill, however my heart rate when doing so is a fair bit lower than your.
Individuals vary in maximum heart rate. I'm only doing about 162 when I do 13.33 mets.
I'm not sure what my current maximum met is now, because I have not tested in the past year, but I ride my bike more now.
At any rate, unless you notice problems, you seem to be hunting for something that probably won't affect you for some time.
Certainly not before you will have been on Medicare for some time.
Then, "if needed", you might get some other test.
Again, I don't understand all the technical stuff in your report, but I'm guessing doctors won't want to follow up on your report, given the great production you achieved on the treadmill.
http://www.exrx.net/Calculators/Treadmill.html